S i n g l e C a s e S t u d y A 7 2 -Y e a r - O l d L a d y w it h U r i n a r y In c o n t i n e n c e : A C a s e S t u d y AB ST R A C T: Urinary incontinence is afar-reaching and complex problem fo r older persons and has major psychosocial, economic and health conse­ quences in affected women. The aim o f this case report is to demonstrate that simple physiotherapeutic intervention can bring about dramatic improve­ ment in the continence status o f a patient and as a result improve the quality o f life o f such a patient. A literary review, the patient history, profile and the findings o f the physical examination are presented. Physiotherapy and the outcomes are fu th er discussed. KEYWORDS: PHYSICAL THERAPY, URINARY INCONTINENCE, CONSERVATIVE MANAGEMENT VAN DER SPUY A, Dip Physio (UOF); HED (UP) ' PAPADOPOULOS M, MSc Physio (WITS)2 ’Department of Physiotherapy, University of Pretoria Department of Physiotherapy, University o f Pretoria Urinary incontinence is a far- reaching and complex complaint amongst older persons and has m ajor p sy cho social, econom ic and health consequences in affected women (Hertzog & Fultz, 1990). The physio­ therapist can play a vital part in alleviat­ ing the symptoms of incontinence and thereby improving the quality of life in patients suffering from urinary inconti­ nence. The aim of this case report is to dem onstrate that simple physiothera­ peutic intervention can bring about dra­ matic improvement in the continence status of a patient and as a result improve the quality of life of such a patient. PATIENT PROFILE AND HISTORY The patient (a 72-year-old lady) was referred for physiotherapy, by the depart­ ment of urology, University of Pretoria, with a diagnosis of severe stress inconti­ nence. She had had numerous consul­ tations with different urologists but had never been referred for physiotherapy. As she couldn’t find a physiotherapist in her vicinity agreeable to treat her, she contacted, on her own initiative, the physiotherapy department at the Univer­ sity o f Pretoria. The patient had been suffering from stress incontinence for the past eleven years. She has two children who were bom by means of vaginal delivery and with instrumentation. After the second birth she rem em bers suffering from mild incontinence. Her incontinence started after she had a vaginal hysterectomy eleven years ago. Since then she has undergone seven surgical procedures for her incontinence but to no avail. For the past four years, it has rendered her housebound and unable to socialise, shop or attend church services. She described her quality of life as poor. She com ­ plained of recurrent urinary tract infec­ tions, which complicated her situation even further. Apart from her inconti­ nence, she has no other relevant medical problems and uses no medication which could influence her condition. PHYSICAL EXAMINATION On examination, the skin in the groin and around the external genitalia was found to be red and she had a perianal rash. Pelvic floor strength graded 1 out of 3 on the Circumvaginal muscle scale as she was totally unable to contract her paravaginal muscles (Worth et al, 1986). PHYSIOTHERAPY The physiotherapy session started with patient education embracing all the rele­ vant concepts of incontinence. Infor­ mation was given to the patient, as well as to her husband who accompanied her. Initial treatment consisted of interfer­ ential therapy, using an intra-vaginal electrode. A base frequency of 2000Hz was used as it has the best effect on the striated muscle found in the external sphincter of the bladder. Am plitude modulation frequency (AMF) of 50 Hz was used, which has the best circulatory effect (Hogenkamp et al, 1987). A ratio of a 10 to 20 second contraction period and a 50-second rest period was used in order to allow adequate recuperation of the small damaged muscles of the peri­ neum. The treatment time was 30 mi­ nutes and was divided into 2 sessions of 15 minutes each with a 5-minute rest period in-between. The interferential current intensity was maximum, just below the patient’s pain threshold and not causing any discomfort. The patient was encouraged to contract her perineal muscles maximally while the current was surging. During the course of the treatment, progression was aimed at producing a maximal perineal muscle contraction with a progressively lower current intensity. The patient was treated CORRESPONDENCE: Ms A van der Spuy Department of Physiotherapy University of Pretoria PO Box 667 Pretoria 0001 Tel: (012) 354-2023 SA Jo u r n a l o f P h y s io t h e r a p y 1999 V o l 55 No 3 21 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 3 times a week for a total number of 12 treatments. By the second week of treatment ( 4 ^ treatment), in addition to the interferen­ tial therapy, the patient was instructed to do perineal floor muscle exercises (PFME). She was instructed to practice 3 times every day (see Table 1 for fur­ ther details). She was further told to empty her bladder only every two hours and to consciously make use of the peri­ neal muscle floor control which she had attained. The patient reported at each subsequent physiotherapy session that she had diligently followed these instructions. During the third week of treatment ( 8 ^ treatment), vaginal cones, as an addition to her pelvic floor muscle exer­ cises, were added to her exercise pro­ gramme. On her return for the 9 ^ treat­ ment, the patient reported that she had struggled to insert a vaginal cone and therefor could not manage to perform this part of her home-exercise regime. Subsequently the physiotherapist helped her to insert a vaginal cone and to con­ tract her pelvic floor m uscles. T he patient was instructed to re-attempt this exercise at home. At her 1 0 ^ visit to the physiotherapist, the patient again com ­ plained that she had difficulty inserting a vaginal cone. She described it as “awkward” and an “unnatural” exercise for an “old lady” . Any further attempts at using the vaginal cones as part of her exercise programme were therefor discontinued. The patient was told to maintain the perineal muscle strength by constantly contracting her muscles and by consciously using them in bladder control. OUTCOME Table I presents the improvement, both subjectively and objectively,during the 12-session treatment period. The patient reported after the 3rd treatment that she already had better control. She admitted that she previously hadn’t been aware of the fact that a contraction of the perineal muscles is possible. By the 8 ^ treatment she reported that she had improved dramatically and that she had been shop­ ping the previous day. By the 11^1 treat­ ment the patient reported continence for the whole day except towards the late afternoon, when she became tired and had an occasional lapse. The condition of the skin in the groin and genitalia also demonstrated a dramatic improvement by the 1 2 ^ treatment. Six months after completion of the treatment course, the patient was con­ tacted telephonically. She was delighted to report that the recurrent urinary tract infections had disappeared and she was fully continent and that she was once more leading an active and productive life! One year later, she was still continent! DISCUSSION Urinary incontinence is a common prob­ lem in the elderly and it is associated with staggering social and economic costs. Sufferers give up many aspects of their lives with obvious detriment to their social interactions, inter-personal and sexual relationships, careers and psychosocial wellbeing (Kelleher et al, 1997). Affected women initially change their exercise habits and eventually, after particularly frequent incontinent episodes, their social habits. Such was the case in this patient. This patient was desperate to be cured of her inconti­ nence. The seven surgical procedures and the great monthly expense for sani­ tary wear, apart from the discomfort, placed a large financial burden on her and her husband’s lives as pensioners. Conservative m anagement of inconti­ nence has been shown to be effective both in im proving incontinence anc* improving patient well being (Wyman et al, 1992; O ’Brien et al, 1991). Surgical treatment for patients with stress incon­ tinence is indicated in the presence of severe symptoms which have failed to TABLE 1: SUBJECTIVE AND OBJECTIVE IMPROVEMENT IN PELVIC FLOOR MUSCLE STRENGTH AS EVALUATED DURING THE 12 PHYSIOTHERAPY SESSIONS. SESSION PHYSIOTHERAPY PELVIC FLOOR MUSCLE STRENGTH PATIENT COMMENT 1&2&3 Patient education, Interferential therapy. 1/3 N o control over bladder function. 4& 5& 6 A s above. A dd PFME in supine (4 sets of 10). 2/3 "Slightly" more control over bladder function. 7& 8& 9 A s above. A d d PFME in side-lying and standing (4 sets of 20). A dd vaginal cones during session 8. Discontinue vaginal cones from exercise program at session 10. 2/3 "Definite" better control over bladder function. Vaginal cones are "awkward". Went for shopping the day before session-8 - the first time in 4 years. 10& 11& 12 A s above. A d d PFME with coughing, climbing stairs and lifting (4 sets of 30). 3/3 . Fully continent the whole day except towards the evening. 22 SA Jo u r n a l o f Ph y s io t h e r a p y 1999 V o l 55 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) respond to conservative m easures (Hilton, 1987). It is sad that none of the urologists consulted by this lady, ever mentioned the possibility of physiothe­ rapy which could improve her condition. It is speculated that the reasons for this might be: either that the urologists were not aware of the beneficial effects of physiotherapy for incontinence, or that they might not have thought that conser­ vative measures could cure this patient. Another factor that should be taken into account was the unavailability of a phys­ iotherapist willing to treat her, even after a urologist had successfully diagnosed her. Physiotherapists need to ask them­ selves “how could this be possible” especially in the light of the fact that the role of physiotherapy in the manage­ ment of incontinence has been well described. It is surprising that physio­ therapists consulted, did not refer her to these specialist-physiotherapists who deal with incontinence. The efficacy of conservative intervention, even in a patient who has undergone several surgi­ cal procedures, cannot and should not be ignored. It is not appropriate however, to extrapolate these findings to other patients in the same situation, as each situation is different and should be assessed under well-controlled circum­ stances. According to Berghams et al (1996) pelvic floor muscle training with bio­ feedback and/or pelvic floor muscle training alone are effective treatment modalities for patients suffering from mild or moderate stress incontinence. In patients with dysfunction of the pelvic floor without awareness of the pelvic floor muscles (i.e. the patient has no ability to contract or relax the pelvic floor muscles), digital assessment by means of transvaginal palpation, per­ formed by the patient or by the physio­ th erap ist, e le ctro stim u latio n and/or biofeedback is indicated. Successful restoration of awareness of these mus­ cles, must be achieved before pelvic floor muscle exercises are possible. Firstly, isolated contractions o f the pelvic floor must be carried out and then incorporating them into activities of daily living, initially during simple tasks and progressing to more complex tasks, in order to achieve a well orchestrated, automatic control of the pelvic floor. The management of this patient was based on this rationale. Electrostimulation (interferential the­ rapy) without biofeedback was used in this patient. De Kruif & Van Wegen (1996) mentioned that electrostimulation focuses on the restoration of reflex activity by excitation of the pudendal nerves, in order to create a pelvic floor muscle contraction. If the pudendal nerve is intact, electrostimulation will induce a motor-response in patients where vo­ luntary contraction of the pelvic floor muscles is a problem, and subsequently re-education of insufficient pelvic floor muscles can be commenced. According to this concept, adequate electrostimu­ lation provides reflex contraction of striated para-and periuretheral muscles, based on afferent excitation of the pelvic floor. If awareness cannot be achieved, the patient has to be sent back for further evaluation by a specialist. An insufficient restoration of awareness can be the con­ sequence of undiagnosed neurologic dis­ orders, sometimes concurrent with endo- pelvic fascia lesions eg after a traumatic delivery. Electrostimulation will also sup­ port the transformation from fatigable fibres to fatigue-resistant fibres (Pette & Vrbova, 1985). Apart from the increase in muscle strength, the improvement in this patient may be attributed to the fact that electrostimulation and exercise resulted in the pelvic muscle fibres becom­ ing fatigue resistant. This was evident from the patient’s report after the 1 1 ^ treatment namely that “she was conti­ nent for the whole day except towards the evening when she became tired”. The fact that the patient couldn’t manage to use the vaginal cones, and described it as “awkward” etc is very interesting. No other documented evi­ dence of this nature has been reported previously to the best knowledge of the authors. Compassionate management of the patient’s predicaments and obvious preferences are extremely important fac­ tors in developing trust and compliance. Incontinence is often cited as being a highly distressing and disabling condi­ tion causing a great deal of anxiety and depression (Resnick, 1996). Additional embarrassment should therefor be pre­ vented at all costs. CONCLUSION Urinary incontinence has a significant effect on an individual ‘s quality of life. Conservative m easures used include education, electrical stim ulation and pelvic floor muscle exercises. Physio­ therapy has been shown to be effective in the management of stress inconti­ nence and can therefor result in a marked improvement in the quality of life of an incontinence sufferer. To achieve these results, constant supervision, support and encouragement must be provided by the physiotherapist. REFERENCES B ergham s LCM , Frederiks C M A , D e B ie R A , Van W aalw ijk van D o o m E SC , Janknegt R A (1 9 96 ): Efficacy o f biofeedback w hen included with p elv ic floor m u scle ex ercise treatment for genuine stress incontinence. N eurourology and U rodynam ics 15:37-52. D e K ruif YP, Van W egen EEH (1 9 96 ): P elvic floo r m u scle ex ercise therapy w ith m yofeed - back for w om an with stress urinary in con ­ tinence: a m eta-analysis. Physiotherapy 82(2): 107 -1 13 . H ertzog A R , Fultz N H (1 9 9 0 ). P revalence and in cid en ce o f urinary in con tinen ce in com - m u n ity-d w ellin g populations. Journal o f the A m erican G eriatrics S ociety 3 8 :27 3-28 1 . H ilto n P (1 9 8 7 ): Urinary in c o n tin e n ce in w om an. British M edical Journal 2 9 5 :4 2 6 -4 3 2 . H ogenkam p M , M ittelm eijer E, Sm its I, Van Stralen C (1 9 87 ): Interferential therapy. Enraf- N on iu s D elft, 3 rd revised edition. K elleher CJ, Cardazo L D , Khullar V, Salvatore S (1997): A new questionnaire to a ssess the quality o f life o f urinary incontinent w om en. British Journal o f O bstetrics an G y n eacolog y 104: 137 4-13 7 9. O ’Brien J, A ustin M , Sethi P, O ’B o y le P (1 9 9 1 ). 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